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Saudi Journal of Kidney Diseases and Transplantation
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EDITORIAL Table of Contents   
Year : 1995  |  Volume : 6  |  Issue : 3  |  Page : 271-274
Incidence of End-Stage Renal Disease: Magnitude of the Problem and its Implications

Ministry of Health, Riyadh, Saudi Arabia

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Data on incidence and prevalence rates of end-stage renal disease (ESRD) from selected countries including Saudi Arabia are provided. Current data from this country suggest that the incidence of treated ESRD (t-ESRD) in the age-group 0-20 years is 14 per million population (PMP) while the combined incidence for all ages is 240 PMP. The cost of management of the patients is staggering. In Japan, it has been estimated that the projected prevalence of t-ESRD will be 1111 PMP needing an estimated budget of US $ 5.8 billion per year for their management. Globally, more than US $ 50 billion would be needed per year with the presently available treatment modalities. This financial liability might make "Health for all by the year 2000" a myth unless some cheaper method of treatment is made available. Vigorous research is needed towards identifying and prioritizing vulnerable groups for ESRD by identifying and properly managing at-risk groups. These include patients with diabetes mellitus and hypertension as well as patients with indicators like proteinuria and obstructive uropathy. Cheaper modes of renal replacement therapy should be sought. Interesting ideas such as induction of diarrhea for amelioration of renal failure need to be explored further as also the use of the patient's own intestine as a medium for molecular exchange.

Keywords: ESRD, Incidence, Prevalence, Cost, Saudi Arabia, Diarrhea therapy.

How to cite this article:
Aziz K. Incidence of End-Stage Renal Disease: Magnitude of the Problem and its Implications. Saudi J Kidney Dis Transpl 1995;6:271-4

How to cite this URL:
Aziz K. Incidence of End-Stage Renal Disease: Magnitude of the Problem and its Implications. Saudi J Kidney Dis Transpl [serial online] 1995 [cited 2021 Apr 16];6:271-4. Available from: https://www.sjkdt.org/text.asp?1995/6/3/271/40660

   Introduction Top

The incidence and prevalence of end-stage renal disease (ESRD) vary from country to country and sometimes from region to region inside a country. Since field-based prospective studies to determine the inci­dence of ESRD would be an overwhelming task, the term treated ESRD (t-ESRD) has become of common usage. Also, some studies when reporting ESRD incidence rates are in actuality, documenting t-ESRD. A recent report gives some summary statistics for t­-ESRD incidence rates for 1992 in patients per million population (PMP) as follows: Australia 61 PMP, Canada 98.4 PMP and USA about 180 PMP. The prevalence rates were; Australia 403 PMP, Canada 518.5 PMP, France 401 PMP and Lombardy 655 PMP [1] .

The reported annual incidence rates of ESRD in Al-Madinah and Gizan regions of Saudi Arabia are 65.2 and 189 PMP [2] . The overall incidence of ESRD in this country will, in all likelihood, be between the incidence rates in Al-Madinah and Gizan regions. As of March 1986, the prevalence rate of ESRD in Saudi Arabia was reported to be 139 PMP [3] .

Regional variations of ESRD incidence in Saudi Arabia are not exceptional. A study in Georgia, USA, reported significantly higher incidence rates in the coastal plain (South) than the counties in Piedmont Region (North) [4] . Several other studies have highlighted regional variations in the USA with or without linking with race-specific incidence rates. Differences in the incidence rates of ESRD in different racial or ethnic groups have also been well documented [5],[6] .

Field studies to determine the incidence rates are difficult as the sample size needed for both cross sectional and longitudinal studies are too large. In countries where the treatment of ESRD is free, and has been in operation on this basis for a decade or more, it can be assumed that most of the patients with ESRD would be reporting to designated health facilities. In such countries, the incidence rate of ESRD based on retrospective data should give a fair picture. However, there are many developing countries where other priorities of health predominate and the study of ESRD inci­dence rate or its treatment remains to be at best lower in the priority scale.

Age-specific studies on incidence andprevalence rates of ESRD are important as higher rates in younger age groups constitute a greater social and economic burden. Definitions of pediatric cohorts vary from country to country and it is best to classify by groups 0-4, 5-9, 10-14 and 15-19 years. The average age of patients in Gizan region was 37 years compared to 50 years in Al­Madinah [2] . The number of ESRD patients in this study was not sufficient to cover incidence rate in children in the age-group of 10 years and below. The reported t­ESRD incidence rate in the USA among the 0-19 years age-group was 11 PMP in 1990. SCOT data published in this issue of the Journal (page 217) shows that 1% of t­ESRD patients in Saudi Arabia are in the age-group of 10 years and below. From this data it can be deduced that the annual pre­valence of t-ESRD in Saudi Arabia in the group up to 20 years of age is 14 PMP and for all age-groups combined is 240 PMP. In a study involving 36 Saudi Arabian hospitals, the prevalence of chronic renal failure (CRF) in children up to 18 years of age was reported to be 20.4 per million children [7] . These patients constitute a part of potential ESRD patients in Saudi Arabia. Increasing ESRD incidence rates are likely with increasing age. In a recent study from India, it was observed that patients with CRF whose serum creatinine values reached 177 /jmol/1 (2 mg/dl) had an inevitable decline in renal function and almost all such patients ended up with ESRD [8] . From this, and other studies, it appears that a registry of CRF patients is mandatory if we were to project plans for the management of ESRD. Persons of all ages having serum creatinine above their normal values should be included in this registry as potential ESRD patients. In addition, separate registries, with some overlaps, on hypertension and diabetes mellitus would help in the identification of a large number of at-risk CRF patients. The patient on the CRF or at-risk CRF registries should receive intensive health education on measures that are likely to slow down the progression to CRF and of CRF to ESRD. The general population who are not in this registry or registries should receive health education on preventive measures on CRF. Also, indicators for preventive measures like diabetes, hypertension, proteinuria, pyelonephritis, obstructive uropathy, racial/ ethnic groups, geographic area, drugs and certain infections should be prioritized in order to identify vulnerable groups. Effective health education in high priority areas aimed at the reduction of ESRD incidence rates, can ultimately be very cost effective both in monetary terms and social costs. A limited view of progression of CRF in the study population published in this issue of the Journal [2] was to divide the CRF patients into several groups with a view to take special care of patients who were progressing rapidly to ESRD [9] . Studies on progression of CRF to ESRD based on individual patient data could further reveal the vulnerable groups for ESRD. One of the objectives of the ESRD prevention program should also be to push the age of acquiring ESRD higher. However, increase in the geriatric population will automatically push the average age-specific incidence rate towards higher age and prevention of ESRD in this population is going to be an important and additional problem of the future. It remains to be seen how the age-specific t­ESRD prevalence rate will be in the future in Saudi Arabia as life expectancy and quality of life improve further in the Kingdom.

One of the major impacts of ESRD is the economic burden it imposes. In the year 1991, the total estimated expenditure on the management of ESRD patients in USA was US $ 8.59 billion, at approximately US $40,000 per patient [10] . The estimate for Medicare program expenditure in 1989 was US $ 35,100 per patient per year and in 1990 was US $ 36,600 [11] . The use of high technology products for the treatment of ESRD either for dialysis or for transplant­ation is an important factor contributing to the high cost. This part of the expenditure is going to be fairly uniform globally as high technology supplies are to be purchased from limited sources. With this high cost of treatment of ESRD, each country has to address the question of incidence and prevalence of ESRD individually.

In Japan, it is predicted that the number of ESRD cases in the year 2000 would be 1111 PMP or higher [12] possibly needing a budget of approximately US $ 5.8 billion per year for the treatment. On a global basis, it is likely that in the year 2000 the prevalence of t-ESRD would be 60 to 70% higher than that of 1995. Thus, projected to the future, the total cost world wide for the management of patients with ESRD is mind-boggling and with the presently available treatment modalities, by the year 2000, more than US $ 50 billion will be needed annually on a global basis to treat the prevalent ESRD cases. This financial liability might make "Health for all by the year 2000" a myth unless some cheaper method of treatment is made available. It is time that an International Center on Kidney Diseases and their treatment is formed with the overall objectives of cutting costs on ESRD treatment and the proper cost effective management of CRF patients. Also, it is of utmost importance to find a cheaper mode of treatment. A simile can be made to the use of oral rehydration salt solution for the treatment of diarrhea [13],[14] . This comparison is being used only to give an example of a low cost treatment popularized recently. I would also like to draw the attention of scientists to carry out research on the whole gut model focusing on active secretion into the gut of waste products from the blood of patients with ESRD. It may be possible, with intensive research, to be able to use the ESRD patient's own intestine for dialysis. It may not end up as the ideal method but may be a life saver for millions of patients in the developing world.

The suggestion to use diarrhea as a limited treatment for ESRD patients [15] has not been taken up seriously. This recommend­ation and the results published so far on the bi-directional flux and net secretion across the intestinal wall, may form a scientific basis for enhancing research interests in this field. Human volunteers for this study could initially be drawn from pre-dialysis patients as their life is not immediately threatened if no dialysis is carried out. Such patients may benefit from this research, as the minor discomfort of occasional controlled diarrhea may result in improvement in their quality of life.

   References Top

1.Anonymous. Worldwide registry information compares the US dialysis population with several other countries. Contemp Dial Nephrol 1995;16(3):9-10.   Back to cited text no. 1    
2.Mitwalli AH, Al-Swailem AR, Aziz KMS, et al. The incidence of end-stage renal disease in two regions of Kingdom of Saudi Arabia. Saudi J Kidney Dis Transplant 1995;6(3):280-5.  Back to cited text no. 2    
3.Ibrahim MA, Kordy MN. End-stage renal disease (ESRD) in Saudi Arabia. Asia Pac J Public Health 1992-93;6(3):140-5.   Back to cited text no. 3    
4.McClellan W, Brogan D. The epidemiology of end-stage renal disease in Georgia. J Med Assoc Ga 1990;79(3):153-6.   Back to cited text no. 4    
5.Easterling RE. Racial factors in the incidence and causation of end-stage renal disease (ESRD). Trans Am Soc Artif Intern Organs 1977;23:28-33.  Back to cited text no. 5    
6.Rosansky SJ, Huntsberger TL, Jackson K, Eggers P. Comparative incidence rates of end­ stage renal disease treatment by state. Am J Nephrol 1990;10(3): 198-204.  Back to cited text no. 6    
7.Aldrees A, Kurpad R, Al-Sabban EA, Ikram M, Abu-Aisha H. Chronic renal failure in children in 36 Saudi Arabian hospitals. Saudi Kidney Dis Transplant Bull 1991;2(3):134-8  Back to cited text no. 7    
8.Mani MK. Chronic renal failure in India. Nephrol Dial Transplant 1993;8(8):684-9.   Back to cited text no. 8    
9.Aziz KMS, Mitwalli A, Aswad S, Al­Swailem AR, Paul TT. Progression of chronic renal failure in a prospective study in Saudi Arabia (abstract). Saudi Kidney Dis Transplant Bull 1992;3(1):49.  Back to cited text no. 9    
10.Norris KC, Owen WF Jr. The dilemma of hypertension in the ESRD African American Community. Nephrology News & Issues 1995;9(3):14-16.  Back to cited text no. 10    
11.Excerpts from US Renal Data System, 1993 Annual Data Report, National Institute of Diabetes and Digestive and Kidney Diseases, The National Institutes of Health, Bathesda, MD, March 1993. Am J Kidney Dis 1993;22(4 Suppl 2):1-118.  Back to cited text no. 11    
12.Moto-hashi Y, Nishi S. Prediction of end­stage renal disease patient population in Japan by system dynamics model. Int J Epidemiol 1991;20(4):1032-6.  Back to cited text no. 12    
13.Hirschhorn N, Kinzie JL, Sachar BD, et al. Decrease in net stool output in cholera during intestinal perfusion with glucose-containing solutions. N Engl J Med 1968;279:176-81.  Back to cited text no. 13    
14.Rahaman MM, Aziz KMS, Patwari Y, Munshi MH. Diarrhoeal mortality in two Bangladeshi villages with and without community-based oral rehydration therapy. Lancet 1979;2:809-12.  Back to cited text no. 14    
15.Young TK, Lee SC, Tang CK. Diarrhea therapy of uremia. Clin Nephrol 1979;11:86-91.  Back to cited text no. 15    

Correspondence Address:
K.M.S Aziz
P.O. Box 27049, Riyadh 11417
Saudi Arabia
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PMID: 18583733

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